Medi-Cal Rx News
Medi-Cal Rx Update:
Implementation of Phase I, Wave III - Reinstatement of Prior Authorizations for 11 Drug Classes
The Department of Health Care Services (DHCS) has announced a proposed plan for reinstatement of claim edits and prior authorizations (PAs), as well as phasing out of the Transition Policy for Medi-Cal Rx. DHCS presented a three-phase plan that includes reinstatement of PAs for new start medications based upon drug classes. This approach allows providers to initiate PAs on a gradual basis while DHCS continues to grandfather prescriptions with historical claims or PAs.
On September 16, 2022, Phase I, Wave III of the Reinstatement Plan will go-live. Providers will be required to submit PAs for new start medications in the 11 identified drug classes below.
- Diuretics
- Lipotropics, including statins and omega-3 fatty acids
- Hypoglycemics, including glucagon
- Coronary vasodilators (nitrates and pulmonary arterial hypertension agents)
- Cardiovascular agents, including antiarrhythmics and inotropes
- Anticoagulants and antiplatelets
- Niacin, Vitamin B, and Vitamin C products
New prescriptions for beneficiaries 21 years of age and under, for medications within the 11 drug classes, are excluded. Specifically, new start prescriptions for children and youth within these 11 drug classes will not be subject to PA reinstatement.
For any questions regarding the implementation of Phase I, Wave III, please contact Medi-Cal Rx at (800) 977-2272 or CenCal Health Pharmacy Department at (805) 562-1080.
Reinstatement of Reject Code 88 & Postponement of Reject Code 80
What is Happening?
Effective July 22, 2022, Drug Utilization Review (DUR) claim edits will be reinstated. Specifically, claims will reject for National Council for Prescription Drug Programs (NCPDP) Reject Code 88 – Drug Utilization Review Reject Error for DUR alerts such as drug-drug interactions, high dose, early refill, etc.
Review Medi-Cal Rx billing guidelines in the NCPDP Reject Code 88 DUR Reference Guide to avoid or resolve claim rejections.
The Department of Health Care Services (DHCS) has elected to postpone implementation of the National Council for Prescription Drug Programs (NCPDP) Reject Code 80 - Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.
Claims submitted to Medi-Cal Rx will NOT be edited for a diagnosis code as planned to begin July 22, 2022. However, providers are reminded of their obligation to document the meeting of Code 1 restrictions and to keep that information readily available.
Please contact the Pharmacy Department with any questions at (805) 562-1080.
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